Residency Spotlight

An Interview with John Marx, MD

John Marx is the Chair and Chief of the Department of Emergency Medicine at Carolinas Medical Center in Charlotte, North Carolina. Marx joined Denver Health as an emergency medicine resident in 1978 and continued on as an attending physician in Denver for a decade after completing residency. During his tenure at Denver Health, Marx held numerous roles—including research director and director of medical students—and was honored with four Master Teacher awards. In addition to authoring numerous peer-reviewed, original manuscripts, Marx has served as Editor-in-Chief of Rosen’s Emergency Medicine: Concepts and Clinical Practice textbook for the past two editions. He spoke with Heather Prouty, a fourth-year resident at Denver Health.

How did you decide to come to Denver for residency?

I loved the atmosphere and what I had heard about the place. I’m a city/county hospital kind of person. I enjoy the opportunity to take care of the underserved and the un- and underinsured. And I love trauma and the excitement of a big city hospital—and DG seemed to fit the picture.

Emergency medicine was a relatively new specialty at that time. Did anyone encourage you to consider other options?

First of all, I had barely heard of it, and there was no one at my medical school [Stanford] who knew anything about it. There wasn’t anyone I could approach. People encouraged me to go into internal medicine, which is what I started out in. I came to the notion of emergency medicine because I wanted to be able to care for anybody at anytime. So, if somebody knocked on my door at three in the morning, I could run over to the neighbor’s house and start providing care to somebody, as opposed to an ob/gyn, dermatologist, radiologist or anybody else.

Was I discouraged? Yes, I was, by those who felt that emergency medicine was too new of a field and by people who had a misunderstanding or complete lack of understanding of what emergency medicine was.

You alluded to this in the previous question, but what was it that drew you to Emergency Medicine?

First of all, it was a new field, and I was interested in academics. I thought because it was new, it might be an opportunity for me to pursue academics as a career and get in on the ground floor which still existed back then.

The idea that emergency medicine covered all fields was interesting because it was a bit contradictory to my personality. In college, I was a biochemistry major. I liked the idea of being able to have complete knowledge of a subject before walking into a final. In emergency medicine, there ain’t no way you can do that. You have to be accomplished in every single field, but to be the expert in that field is an impossible task. So I was going into something that was going to challenge me and challenge the way I had looked at medicine, if not at life, prior to that point.

The other [idea] is being able to take care of people in that special moment in their life—when they haven’t expected to wake up in the morning and have their wife die or have their child be severely injured or paralyzed in a car crash. There are many magic moments that have come from that in my career. Being able to be with patients in those partly miraculous, partly tragic times is a tremendous opportunity.

Has the specialty lived up to your expectations?

It has surpassed my expectations. I’ve been lucky as hell—the people I’ve met, the opportunities I’ve had, the colleagues I have. The times truly have gotten tremendously better for emergency medicine. The fact that for the last 15 or 20 years we’ve been one of the top several specialties on a year-to-year basis has allowed us to recruit the best residents from medical school. That has allowed us to gain respect and to have a great foundation of individuals who really wanted to make a difference in emergency medicine and in medicine generally. Routinely, emergency medicine within a medical school or hospital is highly respected because of this passage of 15 or 20 years of being able to acquire the cream of the crop.

Who were some of your mentors in Denver?

Everyone was a mentor. Vince [Markovchick] was my program director and Peter [Rosen] was my chair. My chief residents were mentors. People in my own resident class were very generous with their time and knowledge and helped shepherd me through.

Obviously, Peter was a tremendous mentor just by his actions. Really, it was when I came to Carolinas in 1991 and started having to make decisions like those that any chair makes that I realized how much Peter had imbued in me many of the tenets of what it means to be an emergency physician, what it requires, what you have to do to defend your specialty and your patients. It was then that I knew he had truly been a mentor because I was in some ways behaving like him. I would realize that my answers were responses to certain situations and echoed what he had done some 15 years prior.

What were some of the lessons that you learned in residency that are still with you today?

Again, it is privilege to take care of patients and try to make their lives a little better, especially people who really have no recourse other than to come to us. That’s something that has always been with me.

I also realized that in emergency medicine you have to work hard all the time. That remains true today for me, and I’ve been in emergency medicine for 29 years. A lot of the patients are pretty straightforward and their illnesses are easy to recognize and treat. But you always have to be on your toes for that 16 year old who comes in vomiting with a sort of low blood pressure. You can either say it’s gastroenteritis or you can say, ‘Wow, I wonder if she has adrenal insufficiency.’ If you miss that opportunity, then she literally could die from it. We have a heavy set of responsibilities, and what we do is extraordinarily difficult. It takes tremendous diligence, patience and thoroughness, yet speed, quick decision-making and common sense.

Back in the ’70s, we would get applicants who thought emergency medicine would be a lifestyle choice and that it would be really easy. I have never looked at it that way. It is an enormously difficult, if not the most difficult, specialty. When you get that phone call, ‘Remember that patient you took care of last night?’ it’s like getting hit with a hammer. You have to live with what may have been a mistake on your part or not doing whatever was necessary to do the right thing. You end up with something on your conscience that—at least for me—never leaves.

What advice would you offer to residents at each level of their training?

Number one, what a privilege it is.

Number two, that residents have the opportunity to contribute to the greatness of our specialty in many different ways. You can be a politician, teacher, program director, researcher, community liaison about safe practices with driving and safety restraints, and on and on. There are many ways that you can make a difference.

Third, it is an incredibly difficult specialty. Be prepared to work hard on every shift and to do so for the entirety of your career. It does not get easier. You get more experience, but you have to keep up with the knowledge. Those would be my major three messages. They don’t change from class to class; they prevail throughout training and beyond.

Can you tell us about your career path since leaving Denver?

First of all, Peter Rosen and colleagues of mine who had gone on to be chairs had said, ‘You need to go be a chair somewhere.’ And I would routinely answer vigorously that I couldn’t see myself doing that. I thought it would be too administrative. Then, as I stayed in Denver for an increasing number of years, I realized maybe there was a next encounter that lay ahead for me.

It was one of those completely serendipitous deals where I got a phone call from somebody here [at Carolinas], who had done toxicology work in Denver and then came to this faculty. I said, ‘Where are you?’ and he said, ‘Charlotte.’ And I said, ‘Where’s Charlotte?’ not knowing Charlotte from Charleston, South Carolina, from Charleston, West Virginia, from Charlottesville, Virginia. I got a phone call the next day and got invited out.

There was no Chair 101 course. Basically, it’s like anything else. You come on board and you figure it out as you go and hope that people will help you out and not take advantage of you. I came out not really knowing what I was heading into, and it’s been a really great ride.

You’re involved in quite a bit of research and editorial work. Can you talk about that?

I was involved with research when I was in Denver, and I promised when I came here that I would spend two years figuring out how to be chair and then get back to my research. For the most part, I haven’t had much opportunity to do that, but I’ve tried to foster that notion in others.

As for the first edition of Rosen’s, I went to the University of Colorado library and took out every book I could find and about 500 papers. Without the advantage of a computer, since it did not exist at that time—at least not a PC—I wrote the chapter. That was sort of the beginning of my doing non-peer review work. Peter was gracious enough to honor me with the chance to take on the Editor-in-Chief role of the Rosen’s text after its first four editions. That’s been very rewarding.

You’ve accomplished so much in your career. What’s next?

I have learned that there’s no counseling service that takes old people in emergency medicine [laughs] and sits down with them and says, ‘Here are some opportunities for you.’ So I’m beginning here in the next couple of years to look around and see what else I can do and make a difference.

We are likely to become a campus for UNC Chapel Hill, and we may grow from that into a full medical school at some point. I would be very interested in having some leadership in that undertaking. That would be fun for me.